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Critical Care help!

  1. #1
    Exclamation Critical Care help!
    Medical Coding Books
    I have been working with the provider for a year now because noone else has been able to get through to him. I have presented numerous articles along with cpt guidelines and CMS guidelines but he is set on billing critical care. I have problems with most of the notes he is billing and would like some of your expert opinions. Here are a few examples:
    CC 35 min
    Pt sedated on vent + tracheal secretions
    37.6, 106, 14, 92/42, 98% on 40%

    chest: no wheeze, good air extry
    cvs: no gallop
    abd: soft
    ext: no edema

    (referenced multiple labs)
    trop: 46 7.5/35/108/27 on vent
    x-ray chest: improving pulmonary edema

    Resp failure Acute due to AMI/pulmonary edema
    Cardiogenic shock on levopred
    L hip fx s/p orif
    cont. levopred
    vent adjusted
    wean as tolerated
    tube feeds
    type & cross match & transfuse 2 units of PRBC
    watch renal function & lytes
    pt's family updated about her medical condition
    poor prognosis.

    CC 35 min
    Pt awake tolerating vent minimal trachael secretions, low grade temp 38.2
    104, 172/65, 20 100% on 40% FIO2
    chest: no wheeze, decreased air exchange
    cv: no gallop
    abd: nt, + bs
    ext: 1+ edema

    (noted many labs)

    Acute resp failure - vent dependant
    End stage COPD with exacerbation

    IV steroids
    vent support
    pan-culture - on cefepin, fluconozole, levaquin
    tolerating tube feed
    transfusion per nephro
    EPC cuffs


    Any input would be great!
    Mandy Flagg, CPC, CEMC
    Compliance Auditor

  2. #2
    Milwaukee WI
    Default Why Do You Think These Are NOT Critical Care?
    Why do you think these notes do NOT qualify as documentation for critical care?

    I have my suspicions as to your thinking, but would like to know before I respond.

    F Tessa Bartels, CPC, CEMC

  3. #3
    Default My reasoning
    The reason I do not believe that these would qualify as critical care is because of my interpretation of the rules. In Publication 100-4, 12, 30.6.12 the definition states: A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient's condition. This to me means that there is an ACUTE, URGENT need for the patient to be seen IE: sudden decline in condition, code, sudden instablility in vitals/status, etc. Just because the patient is on a vent and that vent needs adjusted does not mean that patient requires "critical care" I know that these patients have respiratory failure however the way these notes are written make me think that that patient has this condition however is stable.

    Does that make sense?
    Mandy Flagg, CPC, CEMC
    Compliance Auditor

  4. #4
    Milwaukee WI
    Default Critically Ill
    I know one physician who wil not bill critical care unless the person is in imminent danger of death.

    But the guidelines do NOT say the person has to be acutely in danger.

    For patient number one your documentation includes:
    Resp failure Acute due to AMI/pulmonary edema
    Cardiogenic shock
    type & cross match & transfuse 2 units of PRBC
    poor prognosis

    For patient number two documentation includes:
    End stage COPD with exacerbation
    pan-culture - on cefepin, fluconozole, levaquin
    transfusion per nephro

    In both cases I think you could make an adequate argument that the patient's illness/disease process is acutely impairing one or more vital organ systems ... i.e. critically ill. And that the physician is trying to treat those systems.

    However, all I see for time is : CC 35 min
    When I see the abbreviation "CC" I think Chief Complaint.
    I like to see "I spent 35 minutes in direct critical care time with this patient."

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  5. #5
    Nashville AAPC Chapter
    I would have to agree with Teresa, I found this description on Trailblazer-MCR website.

    "A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient's condition."

    The physician must be at the bedside for the full 35 minutes and it appears as if this was documented correctly. I would agree with Teresa, that it would be better to document out the CC to critical care, that could be a transcriptionist issue - but would be worth the clarification for auditing purposes.

  6. #6
    Thanks Ladies,
    Maybe my understanding of critical care is mistaken, I was under the impression that the patient had to be unstable to the point that it was a threat to life? I did not think that if they documented that the patient is sedated and not in any distress that that would more than likely qualify as a high level visit and not critical care. I have been trying to research this for so long and there is not alot of information out there.

    Again, I really appreciate your help!
    Mandy Flagg, CPC, CEMC
    Compliance Auditor

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